The blog is a reflection of multi-disciplinary scholarship, academic degrees, and all kinds of letters after my name to make me feel big. Psychoeducational and happy, I'll lecture at most sunny places, topic your choice. The blog is NOT to diagnose, treat, or replace human to human legal, psychological or medical professional help. References to people, with the exception of myself, and events except those about me, and even some of those, are entirely fictional.

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Sunday, October 30, 2011

For those of you who don't know about Sybil, she had 16 different personalities, according to Flora Rheta Schreiber the woman who made her famous in the book Sybil. Everyone in my generation watched the movie with Joanne Woodward and Sally Field. It was on TV.

Like watching the Three Faces of Eve, seeing what appeared to be real mental illness is scary. As a kid you think, who could fake this?

Now along comes a journalist determined to find the real story, and like any good investigative reporter, she digs in and gets Shirley Mason's (Sybil) true modus operandi.

We thought Shirley had suffered a childhood trauma, developed "alters" to cope with her terrifying world, but lo and behold, her psychiatrist, with the help of a writer, milked a case of pernicious amnesia to make a lot of money. Anemia isn't nearly as sexy as Multiple Personality Disorder.

For the clinician, the study of personality development is always of interest. How we behave, how we come to respond differently in different situations, why one person is extraverted, another shy, these questions drive research, make up the soul of therapy.

We all have alters, we all have multiple personalities, and most of us know it. Most of our behavior, including breathing and turning off the alarm clock, is unconscious. So why should acting the part of someone more competent, someone more sexy, someone more youthful, someone more distinguished, someone more angry, someone more manipulative, someone more talented, be such a stretch?

And there are so many more roles, so many facets of personality that we try on never thinking about it. Nobody used to say, Just saying, five years ago. Nobody used to say, It's not all about you. Our language is picked up unconsciously, half the time we're not sure from which television show. Indeed some psychologists feel that over ninety percent of what we do, what we say, is unconscious. That should scare us all into watching what comes out of our mouths.

Why wouldn't personality vary, and vary dramatically? Why not have several personalities? And under severe circumstances, behaving differently is the only choice, just saying.

But Carol Tavris's review indicates that Multiple Personality Disorder (MPD), or Dissociative Identity Disorder, as we refer to it now, is all a ruse! The story, and then the movie, inspired thousands of more fake stories! And from this, a classification born.

Now that makes sense. Thousands, not one or two, copy cats. Read with me.

By 1980 so many psychiatrists had begun looking for sensational cases of MPD in their own troubled clients—and finding them—that for the first time it became an official diagnosis in the "Diagnostic and Statistical Manual of Mental Disorders." MPD was a growth industry; eminent hospitals, notably Rush Presbyterian in Chicago, opened MPD treatment centers. By the mid-1990s, according to some estimates, as many as 40,000 cases had been reported.

Yet Sybil's story, which started it all, was a complete fabrication. Sybil, whose real name was Shirley Mason, did not have a childhood trauma that caused her personality to fragment, and her "personalities" were largely generated in response to pressures, subtle and coercive, by her psychiatrist, Cornelia (Connnie) Wilbur, whom she wanted desperately to please.

All well and good, a fake exposed. But to toss out rigorous research, the underpinning of diagnostic classification with the swipe of a pen? She doesn't stop there.

What, then, did Sybil suffer from? Is MPD "real"? Yes and no. MPD is what some psychiatrists call a culture-bound syndrome, a culturally permitted expression of extreme psychological distress, similar to an ataque de nervios (an episode of screaming, crying and agitation) in Hispanic cultures and "running amok" in Malaysia. . .

. . .the promulgators of MPD do not seem to have learned anything. They changed the label to "Dissociative Identity Disorder," but a skunk by any other name is still a skunk.

Oh dear! Promulgators? Now they're promulgators, not teams of mental health researchers rigorously investigating the presentation of a disorder. And to compare Multiple Personality Disorder, or Dissociative Identity Disorder to ataque de nervios, a cultural (Hispanic) panic disorder, is a bastardization of the process, we call this the scientific method, behind the Diagnostic Statistical Manual of the American Psychiatric Association (DSM IV-TR). Call it what you will, and the DSM is under it's 5th revision, but each diagnosis is researched to be determined exclusive. We don't rely upon case study, we frown upon idiopathic research, anecdotal data like the story of Sybil.

To jump from an individual presentation (be it ingenuous or not), to an entire class of mental illness, isn't how diagnostic classification happens. There are no promulgators. And to disseminate it at such is clearly sensationalism, fraud. And to say that those who present with the features of Dissociative Identity Disorder (DID) or Multiple Personality Disorder (see my post) are faking it, is a total disrespect to the thousands who suffer the disorder.

Those of us who treat mental illness do find cases of the disorder, and they are severe, and they usually have roots in childhood trauma. Those who have been profoundly abused usually don't seek help, certainly can't afford the type of psychiatric care afforded to Shirley Mason. They haven't the resources, their lives have been altered, and occasionally, their personalities, just like yours and mine are altered, but in a more pronounced fashion. They are clearly mentally ill.

Call a skunk a skunk, I say. But it isn't the psychiatric profession that stinks here.

Monday, October 24, 2011

(1) I understand that New York therapists take off the entire month of August.

But my habit, being a Chicagoan (as opposed to a New Yorker) is to take off Jewish holidays and an occasional mental health day. Or week.

This is Jewish holiday season, which includes: (a) the Jewish New Year (Rosh HaShana) contemplations, regrets, mainly, about the old year; (b) the Day of Atonement (Yom Kippur), that fast we'll talk about later, and (c) a couple of lesser known chaggim (hard "ch", festival in Hebrew), Succot and Shemini Atzeret, or Simchas Torah. So I haven't been to work all that much this October. Anyone trying to reach me at the office heard a variant of this:

Hi, it's Dr. ____. I'll be out of the office until __(date)___. You'll hear from me then if you leave a message.

If this is a life threatening emergency, call 911 or go to an emergency room. Have someone contact your primary care physician.

If you feel it's urgent, but it is not an emergency, you can call
_(first name) (last name)__ and ask him to call you back. (First name)__ is on call for non-emergencies. Thanks so much.

In other words, See ya'.

As a younger therapy doc, the only way not to make a mistake in this recitation would be to read the message from a scrap of paper, not unlike scripting a phone conversation with a patient suffering from social anxiety waiting to hear about a job or a date.

Reading from a script only empowers a person so far. In my case, the wrong inflection requires re-recording the message as many times as it takes to get it right. The tone of the voice-mail can't sound too happy or too glib, and certainly not self-satisfied. The only humane way to get it right is to try to empathize with callers, to guess how they'll respond. My hunch is many respond like this:

Uh, duh! Like I don't know about 911?

Or

No freaking way I'm calling someone I've never met just because it's "urgent".

Or

What's a primary care physician?

Or

She never told me she was going on vacation! The chutzpah! (Chutzpah rhymes with puts-the, hard "ch", Hebrew for gall, or nerve).

(2) If you know me, then you know I never take real vacations, not the kind where you go whitewater rafting or see monkeys in rain forests; not kicking back vacations, drinking margaritas or whatever the cool drinks are these days, or sight-seeing in Peru or Italy.

Having successfully launched most of our children, FD and I think of a vacation as seeing family, feeding them or being fed, and taking the little ones off on urban adventures. Or just playing cards. The cards are tossed in the trash after the kids visit because we find them everywhere. Without the kids around, there's no point in trying to make decks. And my father left me an entire duffel bag of unopened decks, anyway. No fool.

Combine the family vacay or in this case, stay-cay with a Jewish holiday or five, and you have many, many people, most of them first or second degrees, under one modest roof, with visitors.

The toughest decision I generally have to make is this: Do I go to services? (Meaning the synagogue). Or would it be better to whip up batches of pancakes and french toast? This decision all depends upon the seriousness of the particular holiday. The pancakes are blueberry, the french toast pan fried with the brown sugar, butter and maple syrup.

This year the kids visited us, meaning that cooking, sweeping, straightening up, and throwing an occasional baseball or tennis ball occupied most of my time. If you do this with a future major league pitcher, wear gloves.

That the online expert is only okay with the med-vacay is disheartening. The thinking, never mess with what is kind of working, paired with a long list of possible physical, social, and emotional consequences for messing with it, essentially marries the patient to medication. And it makes a baseline comparisons impossible. Over the years, who knows what normal is anymore?

That said, if you are considering going off medication, of course discuss it with your doctor first. But keep in mind that how you feel at any given moment depends upon a host of variables, like maturation, events (history), things that may have nothing whatsoever to do with whether or not you're taking medication.

And that laundry list of warnings (in the AOL article), the dire consequences that might transpire should you go off prescription medication, is bloated. Anything can happen and probably will, but it may have nothing to do with missing doses, although it is possible, which is why you first talk to your doctor. Find out what anything is, if you can. Maybe it's not so bad, and maybe it is something you need to work on. And talk to your doc.

My most memorable adult patient with Attention Deficit Disorder was a middle-aged male who had been on ADD meds his whole life. He had no life, not one after work. First visit he fell asleep on my sofa, didn't budge for 45 minutes, a 5:30 pm appointment. When at last he woke, he complained to me that he usually falls asleep on a sofa at home by 7 pm, literally waits out the night until morning when he can dose up again to face the next day.

More than one med-vacay might have served him well.

There was no keeping me quiet forever.

(4) We do love our drugs, and that can be a good thing. Most of the time it is. Here's a Facebook status* I posted before taking off for the holidays.
:

Today, at noon, it seemed like such a good idea to make that pot of coffee (5 cups, half caf, choc milk for creamer) and drink it all. Now I'm not so sure.

At 2 a.m., if anyone read that, the third batch of vegetarian gumbo tasted just right, much better than it looked. We would need it for the coming onslaught of eaters.

It can be annoying, especially not drinking any water, but by the end of the fast, the following evening, the light-headed, feint feeling, the emotion, the chorus of hundreds of voices, one of them is yours, everyone is singing, everyone in tennis shoes**, light on their feet, voices rising, rousing the most serious cynic to return to the fold, this has to be the most powerful moment of the year, certainly for some of us. Sheer soul.

Probably all religions have this, some kind of parish sing along, but on the Jewish high holy days, the greatest hits, for us, are second to none. There's healing in the community choir, and of course an incredible rendition of a song you only sing in the church, or the synagogue once a year, has to make you happy.

A cancer survivor told me she can't even go to the synagogue, it's so emotional. (Jewish kids grow up on Barbra, *** who does a nice job with Max Janowski's Avinu Malkeinu, Our Father our King.) Not as powerful as hundreds of voices live, but it will do.

On the way home from the airport on Sunday morning, the first run, alone in the car, I flipped on the radio to hear a mass. Mr. Bach understood the power.

Oh. And FD reminds me, every year, that the day proves that we all eat way too much every other day. We really don't need it. And he's a doctor.

(6) Accountability

The whole thing about the serious holidays, the Jewish New Year and that crazy fast day, is that we're supposed to introspect, retrospect, and consider our flaws. We're supposed to think, Hey, I'm really NOT that good of a person, not nearly the person I should be. I should change!

Not a bad concept, truly, unless you already have low self-esteem. And even then, doing things to raise your self-esteem, consciously making an attempt to do better deeds, be a bigger person, a better person, can't be bad.

A few days after those high holidays, at an early morning circumcision (a new baby, he'll pay dues!), I was yenty-ing (rhymes with gently-ing, Yiddish for chatting) with another friend when she noticed a piece of paper on the floor. She picked it up and we studied a list of things someone actually considered changing about himself in the coming new year.

We were blown away. People do this! They even write it down, they don't just give it a passing thought, change. So if you lost it, take heart that you inspired at least two people, which has to be a good thing.

(7) Apropos of Hugging: The a.m. and the p.m. hug

Cooking the gumbo, on the Adelle station Pandora blasts a song by Christina Perri, Arms. Here are some of the words.

You put your arms around me
And I believe that it's easier for you to let me go
You put your arms around me and I'm home . . .

I hope that you see right through my walls
I hope that you catch me, 'cause I'm already falling
I'll never let a love get so close
You put your arms around me and I'm home

You put your arms around me and I'm home

It's another one of those walls song! But that's not why we're talking about it today. The song made me think of an intervention we use (okay, I use) in couples therapy.

It is a common complaint in therapy that our culture focuses way too much on sex in relationships, and that simple touch, affection, is interpreted as a prelude to sex. And it shouldn't be that way.

Sex isn't what everyone wants. Some, maybe most people prefer pure, unadulterated affection. Not that sex isn't nice. But it shouldn't be the only thing, and maybe shouldn't even take precedence over physical affection. Not all of us learn it at home, and many of us are afraid of rejection, afraid of looking wimpy, even. But as an added relationship seasoning it can make everything feel better. Kiss the proverbial emotional boo-boo, we all have at least one by the end of the day, surely.

But the intervention isn't a kiss, it's the twice a day hug, morning-time and evening-time, if at all possible. This is a standing, full-frontal, full body hug with a main squeeze, partner, lover, or mate. If you have no partner, hug yourself, and keep the intervention, or relationship-skill, if you will, in mind for when you do.

(8) Fall in Chicago

It's here. And I'm back to work, crazy as that feels.

See ya'.

therapydoc

*I don't use Facebook for anything but communicating with family. If you're a TherapyDoc facebook friend, it's because I never got around to deleting that account. When I remember the password, I'll get to it.

**We don't wear leather on this holiday, or gold and silver, either. Why some people lost that part of the observance is a mystery to me.

***I'm not obsessed with Barbara Streisand, but acquired every song, every album, as a kid, and for some reason, I learned every word. On Sunday, visiting my mother at Independent Living (for lack of a better word, we need a contest on this) heard someone belting it out, Don't Rain on My Parade. I went to the common room to hear a cabaret singer who did a really nice job. The whole place was hopping.

For the uninitiated, this is a reciprocation post thanking bloggers who link to my blog, and exposing them for who and what they are, generally awesome.

If you wrote me and I lost your email, please write me again so that I can include you in this post and others like it. You won't see them very often anymore, but I still like the reciprocity of the blogging community, still find bloggers kindred souls, and want to do this. Intention counts for something, doesn't it?

For some reason, the movie people have found me.

Mother's Red Dress -- a film I haven't seen but would like to-- it's featured at The New Social Worker. Karen Zgoda, MSW, LCSW, an ABD doctoral student, pitches the film, a tragic love story about a young man suffering from amnesia, trying to piece together his past.

A Mother In Israel accidentally g-chatted with me, which freaked us both out, but reminded me how nice it is to hang out with people thousands of miles away.

Barbara Kivowitz, In Sickness and in Health, has an op-ed piece in the Chicago Tribune about Pat Robertson's huge faux pas about Alzheimer's (which made fantastic dinner conversation, btw). She's got an upcoming book, In Sickness As in Health. So cool, Barbara!

How about Jack's blog, One Man's War Against Depression? We call it the enemy, but really, substances have first place locked in solid. These are the kind of blogs that make the world a better place, just because people cruising the Internet stop feeling so lonely when they visit.

I have to mention Cheryl at Uppity Crip, naturally, so behavioral, as long as we're looking for great examples.

Kartemquin Films, a Chicago outfit (who knew?), has a soon-to-be released documentary that sounds fabulous, A Sister's Call, about a woman on a journey to help her brother, a man she had disappeared in 1977, suffering from severe paranoid schizophrenia. This sounds like a film I'd like to see. This reconstructing the past thing is big in film now, as it should be.

Now. A relatively new genre of blogger, the infomercial-er. Six years ago you rarely saw this kind of thing, a blog that capitalized on the search engine concept to find readers. It's definitely a good idea, but loses some of that personal touch, that which makes blogging so different from any other type of writing. Nevertheless, for career info, this is the way of the future, and we need this, career information.

And who needs EBAY, seriously, when you can sell your stuff, even professional wares, directly online? If you're a recruiter, what better way to reach potential students or employees? And the only cut they have to give is a link to an idiot blogger's blog!

Oh, as long as we're talking idiot. Has anyone seen MY IDIOT BROTHER? This is a wonderful movie, don't let anyone tell you anything about it, don't even watch the trailer, the link above. Just go. MY IDIOT BROTHER isn't about someone with a learning disability, it's about a really good person who can't help but get into trouble precisely because he's honest. My favorite kind of person.

But back to info-bloggers. These give you a taste of what you can do with your professionalism. You're used to seeing cooking blogs, fashion blogs, media blogs. In this down-economy, get used to seeing academic and employment sites like these, because they're free and Google loves them. And ya' know, getting a degree is going to be the key in the future. It didn't hurt me none.

Friday, October 07, 2011

This is a situation that therapist's see often enough; you might see yourself here.
Switch the she to a he, the he to a she, do whatever you want with the genders. We'll get to Carly Simon after awhile.

File this under empathy training.

A woman comes to therapy because she thought she had a great relationship with a man. She has invested much time and emotional energy to make it work, and it did work, for over a year.

Now she finds that she's not sure about the two of them as a couple anymore. Something has happened. He did something, or hid something, has disappointed her somehow, and she feels very, very angry, although expressing anger is hard. She's not an angry person, and she's not the type that gets depressed, either. So she's strangling, basically.

We discuss childhood, rather than what actually happened, aside from the bare facts, because we're interested in how she turned out as she did, someone who can avoid depression, someone who tends not to get angry.

Sometimes placidity is what we get out of a functional family of origin, sometimes it is learned when the family is anything but functional. Possessing calm is considered a genetic trait. And sometimes, truly, one's defenses simply haven't been tested.

Not surprisingly, we hear that she had at least one physically abusive parent and no protector. The patient's life lesson, her world view, is that it is admirable to be tough, smart to brace for pain, and best to breeze by things you cannot change, quickly. Get your coping skills in a row and use them.

As children, people like her study hard in school. (One of the better things about being a child, for some of us, is that gift of concentrating even when as plates fly in the next room.) Study is an escape from the fracas and it has its benefits: recognition and respect for good grades, fame as an achiever. Self-esteem is salvaged from a dysfunctional childhood all thanks to esteeming educators.

We hear that our patient did excel, earned her degrees, and now earns a good living. She's a problem solver and a fixer in relationships at work, at home, and with friends. But he, her gentleman friend, has erred, and this is a problem she cannot fix. Only he can fix it, he says, and he is working on it.

Neither can escape the fact that his mistake has caused them distance. She won't throw him out, but she isn't warm and fuzzy, either. She wants to make it work, but can't generate any affection, has no desire to touch or hold him, even though he has apologized and is changing before her very eyes. She can't trust the change, feels she has wasted time, a valuable commodity.

You can't wish away anger, is the truth. It has a mind of its own, has to be worked out over time, discharged not with words, necessarily, although these are good, but in our sleep, over television, at work, with each passing day. Anger is invisible negative energy expressed, for some silently, over time, until it is gone.

She can't wish anger away because he deceived her and she trusted him, and trust is not her strong suit. Well before he came around she learned that people disappoint and don't care about the disappointed. Disappointed now, her walls* are up, good, solid walls.

They can be so solid that even the builder can't tear them down, not at will, which is exactly why we say that anger has a mind of its own. Unresolved anger and disappointment are the equivalent of abandonment and loneliness. She didn't sign up for this, didn't commit to it. And who says he won't do it again? Fool me once, shame on you. Fool me twice, shame on me. Better to be alone. There's happiness in a predictable, sensible, good life.

She is in a place she has never been before. Irrational, even to her, she still wants to protect her investment, so she self-reflects, wonders what she is doing wrong. He has been told in therapy that he should talk to her more, should vent, complain, share his feelings. Except that she sees his complaining as self-pitying and childish. She offers solutions to his complaints and he shrugs, walks away, tells her she doesn't understand.

She feels that if anyone has the right to complain about, it would be her, she suffered far more in life. (She may not even voice this in therapy unless you ask, too ashamed of the family dysfunction.) His complaints about his boss, traffic, his sister not returning his calls, whatever, sound lame. She thinks he needs coping skills. She wants someone autonomous, like herself-- a man.

You tell her, "He's human. Bi-peds like to kvetch (rhymes with retch, Yiddish for complain). It is healthy. Part of being a partner is putting up with a little of that, maybe a lot."

"But he won't listen to my advice."

"Did he ask for it?"

"No, but why bother talking about something if you don't want to fix it. All he wants to do is complain and not fix anything."

Why bother talking indeed. Because it feels good, and quells anxiety, dismisses scary thoughts, at least for a little while. And it gets a nice response, if we're lucky:

Hey, that must have felt terrible!'

Therapists say that about fifty times a week. You pay for that emotional validation.

"But he's handling it all wrong!" she cries.

"And he's not ready to hear that."

"Adults want the truth."

Not really. Maybe we'll hear suggestions, stomach the truth, even begin to problem solve, after we are validated. Maybe, if at all.

Think about it from her perspective.* If you were hit as a child for not listening to your parents, or even if you did listen, then you might become quick to respond to the suggestions of others. It is a conditioned response. Those whose opinions mattered aren't so quick to have to change for others, or to please. We want to express our thoughts, uninterrupted. We want to be truly heard.

The psycho-education in a case like this is empathy training, working with the patient to find the missing piece in her interactions with others. It is usually empathy that is missing, the good kind, the one that feels, senses the pain of others, emotional empathy. The other kind, intellectual empathy, is good, too, but it is not as good. To intellectually empathizeis to recognize the feelings of another, identify them, but not feel them, not personally.

The better empathy is the one that is emotionally involved, truly affected by the experience of the other. Feeling the pain along with another may feel bad, but you glom on on anyway. The boundaries between the two of you get gooey, and neither of you cares. This is love as a process, a verb, and it isn't only something between intimate partners. It is just love.

When you tell people about the two kinds of empathy, those who only intellectualize get a blank look on their faces. But most of us feel something, faced with someone who is clearly emoting. Probably the more others empathized with us as children, the more we will empathize with others. But not necessarily. Some say it is all in the genetics, and there is good reason to believe that to be the case. Empathy can be learned regardless, but it will be harder for some than others.

What should she do, she asks you. Her work, at least initially, isn't complicated. She begins by listening patiently to her partner, noticing when he stops ranting, then says, Hey, that must have felt terrible!

Nothing more, unless it is to mirror back what she heard. So he really said that to you, that you probably should consider finding another job? How awful!

For some of us, this is a foreign language. Growing up hard you learn to keep your mouth shut, or life will get worse. Bow your head. Keep quiet. And whatever you do, get things done, and do a good job, avoid too much attention, you'll avoid harassment. And fix something. problem solve. This is the survivor's mantra.

Then along comes a partner, and what he needs in order to grow, to feel better, at least initially, is the option to do the very opposite, to do nothing, to talk out loud.

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About Me

Not here to treat anyone, please understand. So no matter how it might feel or look, I can't be your therapist. If someone tells you that you need it, however, do as my dream license plate suggests, Get Therapy. Community mental health centers can be great, and they're easy on the wallet.